Adult Ed Student Information and ReleaseNeed help? Stop. Go back. Call or email us! Step 1 of 2 0% Name* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Email* Date of Birth* Month Day Year Where did you attend school?* In the United States Not in the United States What would you like to study?* ESL/ELA: Learning the English Language GED/Basic Skills: Preparing for the GED/HiSET and learning basic skills Where would you like to study?* Banks County Barrow County Dawson County Forsyth County Hall County Jackson County Lumpkin County Have you studied with us before?* Yes No What age are you at this time?* Under the age of 16 Age 16 or 17 18 or Above Since you are currently under the age of 16 you are not eligible to participate in our program. Please check back with us after you have turned 16.We strongly encourage students currently enrolled in high school to not drop out. Finishing a high school diploma is always the best course of action. Previous Student InformationHighest School Grade Attended:--Select One--No formal schooling1st grade2nd grade3rd grade4th grade5th grade6th grade7th grade8th grade9th grade10th grade11th grade12th gradeHighest award/degree earned:--Select One--NoneHS DiplomaHS Equivalency (HiSET, GED, etc.)Certificate of Attendance/CompletionSome Postsecondary EducationTechnical/VocationalAssociate’s DegreeBachelor’s DegreeMaster’s DegreeSpecialist’s DegreeDoctorate’s DegreeUnknownDid you attend school in the U.S.A or another country? U.S.A Other Country I have not ever attended school Labor Status: Employed Full Time Employed Part Time Employed, but I have received a notice of termination, facility closure, or I am a transitioning service member. Unemployed and looking for work Not working and not looking for work (Homemaker, retiree, student) Have you or someone in your household received any of the following in the last six months? Select All Temporary Assistance for Needy Families (TANF) Have you received TANF for more than two years in total? Supplemental Nutrition Assistance Program (SNAP), “food stamps” Supplemental Security Income (SSI) State or local income-based public assistance None of the above How many family members, including yourself, have lived in your household in the last six months? 1 2 3 4 5 6 7 8 9 10 or more Release of InformationConsent is valid one year from the date the form is signed by the student.Permission: Military Personnel Department of Labor Court System Parents or Guardians Youth Challenge Other (please explain below) I give permission for the above to have access to the information in my student folder including attendance records, grades, etc. Check all that apply.Other explaination:* Additional permission: Select All I give my permission for my name and/or photo to be included in publications (i.e., graduation programs, brochures, etc.) I will allow my picture on the graduation presentation. I give my permission to release my official GED test scores to my Adult Education Center. I give my permission to the test center to release any demographic and test history information to certain indivduals (list names below). NOTICE: Please consider checking all of these so that we can keep you updated with your scores and be able to send your picture to the newspaper to celebrate your successes!Names of individuals that you allow the center to release information to.* List names separated by a comma.I understand that academic personnel or state officials may have access to student files for program purposes. I also understand that I may be contacted by state officials to provides follow-up information that may be released for analytical purposes only.Signature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.